Table 4.

Governance area 2 – Implementation tools (part 1).

Country	Surveillance	Optimising antimicrobial usage	Infection prevention and control (IPC)
Brunei	Prior/ongoing activities • Data collection on antimicrobial consumption, including appropriateness of usage is ongoing. Future actions • Standardised reference laboratory to be setup and laboratory capacity strengthened. • National surveillance system for antimicrobial resistance (AMR) in human, animal, and environment health sectors to become functional. • Surveillance in public and private hospitals include point prevalence surveys (PPS) on hospital-acquired infections (HAIs) and AMU. • National monitoring system for antimicrobial use (AMU), integrating data from public and private healthcare sectors, and commercial farms and poultry slaughterhouses to be established. • Routine testing of the presence of antibiotic residues in food chain in pipeline.	Antimicrobial Stewardship Programmes (ASPs) Prior/ongoing activities • ASPs were in place in selected facilities in both human and animal sector. • Guidelines for best practices such as National Antibiotic Guidelines and National Guidelines for Prudent Use of Antimicrobials in Livestock, as well as the National Standard Drug List have been developed, and were continuously reviewed and updated. Future actions • Economic incentives that contribute towards inappropriate AMU to be analysed and introduced to encourage judicious AMU. Regulations Prior/ongoing activities • All antimicrobials were classified as prescription only medicines that can only be prescribed by registered professionals. Future actions • Pharmacovigilance Programme and Animal Feed Programme to strengthen regulations to restrict AMU as animal growth promoters and prophylaxis. • All medicinal products intended for human use, must be registered with the Brunei Darussalam Medicines Control Authority, to ensure all marketed medicinal products are safe, efficacious and of good quality. • Veterinary Surgeons Order to ensure veterinarians were licensed and abide by a code of ethics for prudent AMU to be enacted. • Poisons Order to monitor all imported veterinary medicinal products to be enacted.	Policies and guidelines Future actions • National IPC programme, including hand hygiene practices for human health, to be developed. • Programmes for Good Agriculture Practices, Good Animal Husbandry Practices and Veterinary Health Mark for animal health, to be developed. Other strategies Future actions • Human vaccination programmes to be strengthened; guidelines on vaccination requirements for all veterinarians and para vets practicing in the veterinary clinics to be developed. • Campaigns and programmes to educate public and professionals to be established.
Cambodia	Prior/ongoing activities • Strengthening of laboratories capacity. • Ongoing continuous surveillance of AMU in human and animal health and agriculture, including PPS for AMU appropriateness and HAI in humans. Future actions • Centralised laboratory database for AMR surveillance data to be established. • Joint AMR surveillance between human, animal, and environmental sectors to be strengthened to enhance understanding of cross-transmission; early detection mechanism for outbreaks to be implemented. • Antimicrobial residue monitoring in food, agriculture, and environment to be implemented. • Coordination of laboratory and surveillance activities through national and regional network to be supported. •	ASP Future actions • ASPs to be developed and implemented in target health facilities with supporting local policies, staffing, dedicated teams, and budgets. • Guidelines to be implemented in the animal and environmental sectors; AMR to be incorporated in the upcoming revision of Clinical Practice Guidelines, Essential Medicines List, and other guidelines for AMU. Regulations Future actions • Regulatory and legislative frameworks to be reviewed and strengthened in different aspects of AMU, surveillance and monitoring, including AMR response, poor quality medicines, prescription-only dispensing of antimicrobials, waste management, registration of facilities, registration of animal clinics and farms, licensing, AMU for animal disease prevention and growth promoters, and commercial feeds and maximum residue limits. • Services of pharmacies and health facilities to be strengthened through registration and licensing; sanitary and environmental regulations on farm practices for terrestrial and aquatic animals to be strengthened. • Institutional procurement and supply chain systems to be strengthened to ensure availability of quality antibiotics. • No clear mention of authority in place to monitor and enforce legislation.	Policies and guidelines Future actions • National policy and guidelines on IPC to be developed; roles and responsibilities of hospital IPC committees to be strengthened; availability of IPC infrastructure and supplies to be ensured. • Association of Southeast Asian Nations and international good agriculture practice guidelines to be adopted to ensure animal health; provision of IPC infrastructure and hygiene supplies and equipment to be improved in animal clinics, veterinary practices, slaughter facilities and live animal markets. • Infrastructure to be set up to support food safety inspection and analysis. • Best practice guidance to be developed for safe disposal of unused or expired antibiotics and animal feeds, alternatives to antimicrobial growth promoters, waste management, and water monitoring. Other strategies Future actions • Best practice guidance for vaccinations to be developed.
Indonesia	Future actions • Laboratory capacity to be enhanced; reference laboratory to be set up with standardised laboratory operations; standards and guidelines based on international standards to be developed. • National AMR surveillance programme to be implemented for human, animal, food, and aquaculture, including HAI surveillance; surveillance system to allow for early detection of resistance to be developed; surveillance to be extended to district and rural hospitals in public and sentinel private hospitals/chains of hospitals. • AMU monitoring programme in humans and food animals including residues testing in food products to be developed. • National laboratory surveillance network to be established; platform for seamless data transmission to be set up.	ASP Future actions • Comprehensive evidence-based ASPs and guidelines for national ASP in human, animal health care and aquaculture to be established in ambulatory and community settings; ASP to be added into existing hospital accreditation qualifying criteria. • Manuals on the use of antimicrobials, including an essential antibiotics list and standard treatment antimicrobial guidelines in human medicine, veterinary medicine, and aquaculture to be developed. Regulations Future actions • National AMR Containment and Use Policy and related regulatory frameworks to be developed to control the AMU in humans and animals. • Antimicrobial growth promoters to be phased out and certification system of farm products free from antibiotic residue to be established. • Independent periodic surveys to estimate the extent of non-prescription sales of antibiotics to be conducted. • Regulations for antimicrobials (veterinary, human, and aquaculture) and its import, manufacture, quality, distribution, market authorisation, advertising, and inspection, tracking and reporting, to be developed. • Regulations to be enforced by the Drug Regulatory Authority.	Policies and guidelines Future actions • National IPC programme to be established within healthcare settings, animal husbandry systems and fisheries and the food chain; IPC education for healthcare providers, veterinarians, and food handlers to be conducted. • IPC performance with hospital accreditation system for human health to be linked. • IPC biosecurity and vaccination in animal health facilities and farms to be developed, in line with international standards set out by Food and Agriculture Organization (FAO) and OIE, World Organisation for Animal Health. • Coordination with surveillance units in the field of agriculture and environmental health to assess AMR hazard and risk to be established. • Formal campaigns for sanitation and hygiene to be developed. Other strategies Future actions • Human vaccination programme to be strengthened; animal vaccination programmes and campaigns to be established.
Laos	Future actions • Standardised reference laboratory to be set up. • Laboratory capacity to be strengthened; biannual training on laboratory techniques and AMR surveillance. • AMR and AMU to be monitored, including appropriateness, in humans and animals, as well as residues in animal feeds and food products. • Centralised laboratory database for AMR surveillance data to be established.	ASP Future actions • Capacity building on the rational AMU and ASPs for medical doctors, veterinarians, and pharmacists to be provided. • Guidelines on AMU in the animal sector and standardised guideline for management of antibiotic-resistant pathogen in the human sector to be developed. Regulations Future actions • Legislation to be developed to control AMU in humans by declaring antimicrobials as a controlled medicine; monitoring of importation and distribution; sale of antimicrobials only by a qualified professional upon presentation of a prescription. • Regulations for AMU in agriculture and livestock; control the manufacturing, import and export of veterinary drugs and their distribution; regulation to control the production, sale and use of antibiotics in food and water for livestock. • The Food and Drug Law to cover the production/registration/control of quality pharmaceuticals to ensure the quality, efficacy, and safety of antimicrobials. • Food and Drug Department enforces laws and regulations on AMU.	Policies and guidelines Future actions • National strategic plan for IPC in healthcare facilities for human health, and at the national, central, and provincial levels to be developed. • IPC to be improved in government hospital wards. • Agricultural sector to be included at the national level as part of the purview of the IPC committee. • Waste management systems and sanitation plans in hospitals/farms to ensure safe disposal in environment to be set up.
Malaysia	Prior/ongoing activities • Standardised reference laboratory already present. • Ongoing AMU surveillance and HAI in selected hospitals since 2001; regular national PPS on antibiotic utilisation conducted in healthcare facilities. Future actions • Laboratory capacities to be enhanced and test methods standardised across laboratories; capacity of personnel to be improved. • An integrated surveillance on AMR and AMU involving human and animal health was underway; AMR surveillance in place and to be strengthened for animal health and aquaculture. • Alert mechanism for AMR detection and reporting of newly emerged resistance to be developed. • A networking/web-based system between the Ministry of Health, university, and private hospitals to be developed.	ASP Future actions • ASPs to be reinforced at the healthcare facilities with the establishment of ASP policies and teams as a criterion for hospital accreditation. • National Veterinary Antibiotic Guideline and list of controlled antibiotics for food producing animal to developed; National Essential Medicines Lists, National Antibiotic Guideline, and Clinical Pathway for Common Infections to be regularly reviewed. • Critically important antibiotics for human in veterinary/aquaculture use to be phased out. • Introduction of incentives to optimise appropriate use of antimicrobial agents. Regulations Future actions • Distribution, prescription & dispensing of antimicrobials in accordance with national legislation to be ensured; import quantity of specific antibiotics for human and veterinary usage to be monitored; regular inspections/audits planned on the sale of antimicrobial agents in community pharmacies • Regulation on prescription of antimicrobial in animal feed and usage in aquaculture; AMU report as a condition for license application or renewal for farmers. • Pharmacy Enforcement Division and Department of Veterinary Services regulates legislation in human and animal health, respectively.	Policies and guidelines Future actions • National policies and standards of practice on IPC to be strengthened in health facilities for human health, including hand hygiene programmes; National Policies and Procedures on Infection Control to be revised; bi-annual IPC audit and training to be conducted. • Improvement of biosecurity and husbandry for animal health, annual audits in licensed farms and processing plants to be conducted; surveillance and IPC practices according to standards from the OIE to be strengthened. Other strategies Future actions • Vaccination in human and food animals to be promoted; animal health programmes to be optimised by vaccination of pets; market access for products from farm with audit certifications to be facilitated.
Myanmar	Future actions • Reference laboratory to be set up and laboratory operations to be standardised. • National AMR surveillance programme to be implemented in central hospitals, and central and regional veterinary diagnostic laboratories; national early warning system to identify early emergence of resistance to be set up. • AMU monitoring programme in humans and food animals including residues testing in food products to be developed; PPS to assess quantity and quality of AMU in different settings; HAI surveillance in selected public and private healthcare facilities to be expanded further.	ASP Future actions • Comprehensive evidence-based ASPs and guidelines for national ASP in human, animal health and aquaculture to be established in ambulatory and community settings. • Manuals on AMU, including an essential antibiotics list and standard treatment antimicrobial guidelines in human medicine, veterinary medicine, aquaculture, and food production to be developed. Regulations Future actions • National AMR Containment and Use Policy and related regulatory frameworks to be developed to control the AMU in humans and animals. • Antimicrobial growth promoters to be phased out and certification system of farm products free from antibiotic residue to be established; independent periodic surveys to estimate the extent of non-prescription sales of antibiotics to be conducted. • Regulations for antimicrobials (veterinary, human, and aquaculture) and its import, manufacture, quality, distribution, market authorisation, advertising, and inspection, tracking and reporting, to be developed. • Regulations to be enforced by the Drug Regulatory Authority.	Policies and guidelines Future actions • National IPC programme to be established through compliance with the IPC guidelines within healthcare settings, animal husbandry systems and fisheries and the food chain; IPC education for healthcare providers, veterinarians and food handlers. • IPC performance with hospital accreditation system for human health to be linked. • IPC biosecurity and vaccination in animal health facilities and farms to be developed, in line with international standards set out by OIE/FAO; review of existing guidelines. • Coordination with surveillance units in the field of agriculture and environmental health to assess AMR hazard and risk; formal campaigns for sanitation and hygiene to be developed. Other strategies Future actions • Human vaccination programme to be strengthened; animal vaccination programmes and campaigns to be established.
The Philippines	Prior/ongoing activities • Standardised reference laboratory already present; • Sharing of data on emerging resistant pathogens with to AMR surveillance programme. Future actions • Laboratory facilities, equipment, and operations to be standardised and enhanced; trainings of human resources to be conducted. • Expansion of AMR surveillance programme to all hospitals retained by the Department of Health planned. • Integrated surveillance system for AMU, AMR and HAI in human health and livestock to be developed.	ASP Future actions • Development of ASPs in animal husbandry and in hospitals. • Essential medicines lists and national antibiotic guidelines for human and veterinary use to be developed; treatment guidelines for specific diseases to be updated; • Philippine Practice Standards for Pharmacists in relation to Rational Dispensing of Antimicrobials to be institutionalised. • Mainstreaming of complete treatment regimen through reimbursement schemes. Regulations Prior/ongoing activities • The Department of Health and Department of Agriculture strictly enforced regulations on antimicrobial manufacturing, promotion, marketing, prescription, dispensing, and use. Future actions • Issuances related to access (distribution and sales) to antimicrobials to be reviewed. • Database of registered antimicrobials, including quantitative production and importation, and monitoring of unregistered antimicrobials in animals planned • Safety, efficacy, and quality of medicines to be ensured from market authorisation to post-marketing surveillance for sustainable access to quality essential antimicrobials in human and animals.	Policies and guidelines Prior/ongoing activities • Good Animal Husbandry Practices and Good Aquaculture Practices for animal health has been adopted; the ‘Food Safety Act of 2013’ mandated responsibility for health of animals from where food was derived, and the effects of feeds and other production inputs on otherwise healthy animals. Future actions • National Policy on IPC for human health to be developed.
Singapore	Prior/ongoing activities • Food products and animal feed used at food farms are routinely tested for antibiotic residues. Future actions • National AMR reference laboratory to be established. • Standardised test methods and data reporting in alignment with international guidelines to be developed. • Routine HAI PPS surveillance to be established and extended to private hospitals and community settings. • AMR surveillance programme in animal health to be expanded to include all animal production sectors, namely poultry, ruminant and aquaculture farms. • Laboratory capacity for testing of AMR and antibiotic residues in food products to be reviewed. • Independent surveillance across the human, animal, food and environment sectors to be integrated to monitor spread between these sectors.	ASP Prior/ongoing activities • ASPs have been implemented in all public acute hospitals. Future actions • All hospitals (both public and private) were required to implement ASPs, including the monitoring of AMU, through licensing, accreditation, and quality assurance frameworks. • ASPs in veterinary medicine to be developed. • Guidelines on the appropriate AMU in community hospitals, ambulatory facilities (e.g. dialysis centres), and primary care clinics to be issued to improve prescribing practices; national guidelines for prudent AMU in livestock and veterinary medicine to be established. Regulations • Prior/ongoing activities • Antimicrobials for human use were classified as prescription only medicines. • Legislation prohibited use of antimicrobials for growth promotion in Singapore farms, and restricted certain antimicrobials for use in feeds and food-producing livestock and aquaculture farms. • Sales of human therapeutic products for veterinary use was restricted to veterinarians, veterinary centres, and farms. • Health Sciences Authority and Agri-Food and Veterinary Authority regulated legislation in human and animal health respectively, while food safety was overseen by Agri-Food and Veterinary Authority and National Environment Agency. Future actions • Veterinary drug registration system and supply chain control covering import, manufacture, distribution, and sale to be set up.	Policies and guidelines Prior/ongoing activities • Development of the National Infection Control Guidelines for human health and IPC programmes in hospitals. • Introduction of isolation and selective treatments to farms or pet owners ongoing to prevent and manage diseases in animals; good animal husbandry practices and good aquaculture practices have been developed. • Ongoing Sewerage and Drainage Act for managing antimicrobials discharge in environment, with protocols to ensure high hygiene standards to disinfect sewage and remove antimicrobials to prevent waterborne diseases and contamination by antimicrobials; licensing and audits for Toxic Industrial Waste Collectors. Future actions • Food hygiene programme, education of food handlers to improve hygiene standards, and surveillance of pathogens in food to be improved. Other strategies Prior/ongoing activities • Campaigns to promote vaccination; national immunisation policies and guidelines for children, adults, healthcare workers, and travellers; mandatory vaccination for all dogs and cats sold in pet shops; autogenous vaccines in aquaculture; vaccination monitoring and management in farms. • Incentives for good husbandry practices, such as Singapore Quality Egg Scheme for the local layer farms, and Good Aquaculture Practices for Fish Farming.
Thailand	Future actions • Capacity and networking of microbiology laboratories to be strengthened; improvement of epidemiological capacity and networking on AMR planned. • National integrated system of AMR and HAI surveillance and signalling, with alert of emerging pathogens and coordinating systems across agencies at local and national levels to be developed. • AMU in humans, veterinary medicine, and crop production to be measured by using national databases of annual reports of pharmaceutical companies.	ASP Future actions • ASP in animal hospitals and clinics, as well as human healthcare facilities, private clinics, and pharmacies to be implemented. • National policy on promoting rational AMU use in hospitals to be developed. Regulations Prior/ongoing activities • Animal Feed Quality Control Act allowed only registered drugs to be administered under the supervision of veterinarians. • Ministry of Agriculture and Cooperatives regulated production, sales, and use of medicated feed. Future actions • Antimicrobial distribution control system for both humans and animals to be strengthened. • Promulgation of a legislative order on withdrawal of antimicrobials from a household remedy list and restriction of antimicrobials, especially those at high risk of developing resistance, to be prescription only. • Law enforcement to be enhanced along with social measures to mitigate the problem of inappropriate distribution of antimicrobials.	Policies and guidelines Future actions • Efficient systems in healthcare facilities aimed at reducing infection rate and expenses caused by AMR pathogens for human health to be established; measures and systems for management of patients infected by resistant microbes to be developed.
Vietnam	Future actions • National AMR reference laboratory to be established; laboratory capacity, human resources, and equipment to be enhanced; guidelines and standardised test methods to be developed. • National surveillance system on AMU and AMR to be strengthened; system of monitoring and reporting data on hospital infections from hospitals under central authority; warning system to warn about the dangers of AMR to be established. • Monitoring system of safe appropriate AMU in health facilities, livestock, poultry, aquaculture, and cultivation to be established. • Antibiotic residues in foods to be tracked and monitored. • A network to monitoring AMU and AMR in 30 laboratories across the country to be set up.	ASP Future actions • Treatment guidelines for medical staff and community, and list of permitted antimicrobials in livestock, poultry, aquaculture, and cultivation to be developed. • No mention of ASPs or incentives for appropriate AMU. Regulations Future actions • Compliance to treatment guidelines health facilities to be evaluated; guidelines on AMU in livestock, poultry, aquaculture, and cultivation to be improved. • Comprehensive management of drug quality during the entire process of production, export, import, distribution to prevent poor quality and counterfeit drugs from circulating in the market to be ensured. • Investment in production to supply the market with drugs of good quality, reasonable price to be ensured. • The Council of Medicines and Treatment to monitor compliance to regulations.	Policies and guidelines Future actions • Legal documents, policies, national technical regulations, and hospital guidelines for human health to be revised. • Organisation of IPC in examination and treatment facilities to be improved.

Prior/ongoing activities = activities which are either executed once or are still in progress at the point of national action plan publication. Future actions = focus areas and plans to be implemented.

AMR = Antimicrobial resistance. PPS = Point prevalence survey. HAI = Hospital-acquired infection. AMU = Antimicrobial use. ASP = Antimicrobial stewardship programme. IPC = Infection prevention and control. FAO = Food and Agriculture Organization.